Multidisciplinary approach to Pancoast tumors

D. Amoroso

Dip. Di Oncologia Medica

Ospedale Versilia

Lido di Camaiore (Lu)

0%

0%

0%

26%

74%

La vostra definizione di Tumore di Pancoast

23 / 30 Cross-tab label

1. Tumore del solco polmonare superiore che può determinare la sindrome di Pancoast

2. Tumore polmonare caratterizzato dalla sindrome di Pancoast

3. Tumore che origina al di fuori del polmone da residui epiteliali del V arco branchiale

4. Tumore polmonare che determina miosi

5. Tumore polmonare che insorge solo nei fumatori

Introduction

Henry Pancoast: early 20th century

Tobias JW

Introduction

Henry Pancoast: early 20th century

One region…Many names

Location

Arcasoy et al. NEJM 1997

Bruzzi et al RG 2008

Terminology

Clinical Presentation

Arm/shoulder pain Horner’s syndrome Weakness/atrophy or hand muscles

Pancoast’s Syndrome

Clinical Presentation

Most common initial symptom is shoulder pain, produced by neoplastic involvement of the brachial plexus, parietal pleura, endothoracic fascia, vertebral bodies, and 1st, 2nd, 3rd ribs

Treatment for presumed cervical osteoarthritis, or bursitis of the shoulder is not uncommon

A delay of 5 - 10 months in the correct diagnosis has been reported

Horner’s Syndrome

Anisocoria, miosis and left-sided ptosis, anhydrosis

Differential Diagnosis

Malignant Tumor Pancoast’s Tumor Mesothelioma Lymphoma Metastatic Disease

Benign Tumor (most commonly Neurofibroma

Pleural Thickening Status post radiation Infection (i.e. TB,

fungi, hydatid cysts)

Pleural effusion (loculated at apex)

Hematoma Extrapleural from

aortic rupture Vascular aneurysms Iatrogenic (i.e. after

attempted CVC placement)

Associated with rib or vertebral fracture

0%

46%

33%

21%

0%

La diagnosi, secondo voi

24 / 30 Cross-tab label

1. Solo radiologica è sufficiente

2. Si ottiene soprattutto con agobiopsia percutanea

3. Occorre la broncoscopia, la citologia dell’escreato e la RMN

4. E’ clinica e radiologica

5. Va fatta con la PET

Staging/Preoperative Assessment

Limited involvement of the lower trunk or roots (C8 and T1 nerves) of the brachial plexus is regarded as T3 disease

Extensive invasion of the brachial plexus trunk or roots (C5 through C7 nerves), subclavian vessels, vertebral bodies, spinal cord, trachea, or esophagus constitutes T4 disease

Radiographic findings

X-Ray Unilateral cap > 5mm Asymmetry of bilateral caps > 5 mm Apical mass Bone destruction

CT Presence of satellite nodules, parenchymal disease, mediastinal

lymphadenopathy

MRI Evaluation of brachial plexus, subclavian vessels, vertebral bodies,

spinal canal, and chest wall involvement

X-R

ays

findi

ngs

CT findings

MRI scans of tumor

of superior sulcus

PET scan

Diagnostic Work-Up

Sputum cytology (10-20%) Bronchoscopy (30-40%) Percutaneous needle biopsy (90%) VATS Thoracotomy

Pathology

The most common causes are bronchogenic carcinomas < 5% of these involve the superior

sulcus NSCLC (Squamous & Adeno)

predominateSmall cell is rare (< 5%)

0%

4%

0%

92%

4%

La migliore strategia terapeutica, secondo voi

24 / 30 Cross-tab label

1. Consiste nella sola chemioterapia

2. Consiste in un trattamento integrato di chemio-radioterapia preoperatoria e chirurgia

3. Consiste nella sola radioterapia

4. Consiste nella radioterapia seguita da chirurgia

5. Consiste nella chirurgia d’embleè

Treatment

Surgery alone Radiotherapy alone Surgery and Radiotherapy RT followed by en bloc extended

surgical resection Chemotherapy/chemoradiotherapy

plus surgery

Multimodality treatment

Marra et al Eur Respir J 2007

Marra et al Eur Respir J 2007

Surgery

Surgery

Shaw-Paulson’s thoracotomy (posterior approach)

Surgery

Anterior transcervical–thoracic and cervicothoracic transmanubrial incisions

Surgery

The transmanubrial (TMA) approach

Surgery

Surgical complications can be summarized as follows:

Mortality rate (approximately 3-5%) Atelectasis Severe chest pain Air leaks Spinal fluid leaks Horner syndrome Pain

Prognosis

Overall 5-year survival rates with preoperative RT and surgical resection: 30% Patients with uninvolved lymph nodes: 30-40% Patients with incomplete resection, mediastinal nodal

involvement, or T4 vertebral body invasions: <10% 2/3 patients will have recurrent disease Poor prognostic factors:

Presence of Horner’s syndrome Extension of tumor into the base of the neck, great

vessels, or vertebral bodies Involvement of mediastinal lymph nodes

Rusch et al JCO 2007

pCR 29%

Rusch et al JCO 2007

Rusch et al JCO 2007

Rusch et al JCO 2007

Copyright © American Society of Clinical Oncology

Rusch, V. W. et al. J Clin Oncol; 25:313-318 2007

Copyright © American Society of Clinical Oncology

Kunitoh, H. et al. J Clin Oncol; 26:644-649 2008

Fig A1. Study schema of Japan Clinical Oncology Group 9806, with the number of patients who actually received each of the protocol therapy

Copyright © American Society of Clinical Oncology

Kunitoh, H. et al. J Clin Oncol; 26:644-649 2008

Fig A2. Overall survival according to clinical T stage

Copyright © American Society of Clinical Oncology

Kunitoh, H. et al. J Clin Oncol; 26:644-649 2008

Fig A6. Overall survival of patients undergoing surgical resection, with and without pathologic complete response (p-CR)

Back up slides

Rush VW Lancet Oncology 2006

2006